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Nath abdominal trauma

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  • 1. Abdominal Trauma Nat Krairojananan M.D., FRCSTDepartment of Trauma and Emergency Medicine Phramongkutklao Hospital
  • 2. overview• Quick review abdominal anatomy• Review of mechanism of injury• Review of investigation• management
  • 3. Anatomy of abdomen
  • 4. External Anatomy FlankAnterior Backabdomen
  • 5. Visceral organ
  • 6. visceral organ Retroperitoneal spacePelvic cavity
  • 7. Abdominal injuries• No.1 Preventable cause of death• Unrecognized• Closed spaces• Multisystem / multiple organs• Need investigations
  • 8. ATLS protocol Primary survey MaintainC D E A B circulation Stop / seek for bleedingAdjunct to primary survey A Monitoring E B C D investigations
  • 9. Investigations for abdominal trauma • FAST • DPA (DPL) • CT scan
  • 10. FAST: Focused Abdominal Sonography for TraumaAdvantage Disadvatage• Good sensitivity • Operator dependent• Easy to use • Poor evaluation for• Repeatable hollow viscus and• No radiologic exposure retropertoneal injury • Negative FAST?• Really excellent test?
  • 11. DPL: Diagnostic Peritoneal LavageAdvantage Disadvantage• High sensitivity and • Invasive specificity • Poor evaluation for• Hollow viscus injury retropertoneal injury detection
  • 12. DPL: Diagnostic Peritoneal LavageIndications Interpretation• Equivocal abdominal sign DPL positive in• Unexplained shock • Receive 10 ml of gross blood • Cell count:• Unevaluable abdominal – RBC > 100000 status – WBC > 500 – Alcohol / drug • Biochemistry: – Head / spinal injury – amylase > 175 iU/ml – unconscious • Microscopic: – food particle, bile, bacteria
  • 13. DPL• False positive rate in RBC count 11%, esp. in low RBC cell count• False positive rate in WBC count: late DPL
  • 14. Computer Tomography• Great sensitivity and specificity• Detect hollow viscus, retroperitoneal injury• Grading organ injury  non-operative management plan• Blunt VS penetrating
  • 15. Limitation of CT scan• Some hollow viscus and mesenteric injury• Patient’s hemodynamic status
  • 16. Type of injury• Blunt injury• Penetrating injury• Blast injury
  • 17. Algorithm for the management of blunt abdominal trauma Blunt abdominal trauma Clinically Clinically evaluable unevaluable Diffuse No diffuse Hemodynamic abdominal abdominal stable tenderness tenderness Hemodynamic Hemodynamic OR CT + CT - stable labile OR or NOMx observation
  • 18. Hemodynamically labileFAST + FAST - Other causes or No other causes or OR hemodynamically hemodynamically labile present labile present Further evaluation/ DPA + DPA - resuscitation Further OR evaluation/ resuscitation
  • 19. Hemodynamically stable FAST + FAST - CT? CT + CT - observationOR / NOMx observation
  • 20. Algorithm for the management of penetrating abdominal trauma Penetrating abdominal trauma Diffuse Diffuse abdominal abdominal tenderness + tenderness - Hemodynamically Hemodynamically OR stable labile
  • 21. Hemodynamically stableLeft thoracoabdominal No left or right anterior thoracoabdominal thoracoabdominal injury injury laparoscopy GSW SW OR? observation
  • 22. Hemodynamically labile Other cause of No other cause of hemodynamically hemodynamic lability present labilityDPA + DPA - OR OR Further evaluate/ resuscitate
  • 23. Investigation for penetrating injury with hemodynamic stableLocation investigationThoracoabdomen CT scan thoracoscopy laparoscopyAnterior abdominal wall LWE FAST, DPL CTBack and flank CT
  • 24. Options of evaluation in penetrating injury Investigation % Sensitivity % SpecificityPhysical Examination 95-97 100Local Wound 71 77ExplorationDPL 87-100 52-89FAST 46-85 48-95CT scan 97 98
  • 25. Blast Injury Primary Secondary Tertiary QuaternaryBlast wave Shrapnel Blast wind Other consequences
  • 26. Indication for surgery• Hemodynamic unstability• Peritonitis• Inability to• examine patient
  • 27. Non-operative treatment• Solid organ injury only• Hemodynamically stable• No peritonitis• Capable for serial examination immediate investigation and celiotomy if needed• Multiple / combined injury
  • 28. Missed abdominal trauma• Intraabdominal organs – Diaphragmatic injury – Hollow viscus injury – Retroperitoneal injury – Mesenteric injury• Other combined injury
  • 29. Combined injuriesHead and abdominal injuries 5.7%Challenges:• Reliability for abdominal evaluation• Timing of CT evaluation of the head• Severe head trauma in non-operative Mx of abdominal solid organ injury• Major intraabdominal injury with severe blood loss leads secondary brain injury
  • 30. Algorhitm for the management of combined head / abdominal trauma Combined head and abdominal injury Hemodynamically Hemodynamically stable labile GCS < 12 GCS > 12 GCS < 9 GCS > 9 Localizing sign No localizing sign Localizing sign No localizing sign CT before Laparotomy Laparotomy Laparotomy laparotomy before CT Then BH / ICP Follow by CY scan Post op CT scan
  • 31. Pelvic fracture
  • 32. Pelvic Fractures Mechanism• AP compression• Lateral compression• Vertical shear
  • 33. Pelvic FracturesAssessment• Inspection: Leg-length discrepancy, external rotation• Pelvic ring: Pain on palpation of bony pelvic ring• Palpate prostate• Associated injuries• Pelvic bleeding
  • 34. Pelvic FracturesEmergency Management • Fluid resuscitation • Determine if open or closed fracture • Determine associated perineal /GU injuries • Determine need for transfer • Splint pelvic fracture
  • 35. Splinting fractured pelvis• Pelvic wrapping• Pelvic C-clamp• External fixator• ORIF
  • 36. Special considerations
  • 37. Case I: 32 year-old female• GA 37 weeks• G2P1001• Patient model for medical student• On the way home: MCA• Pain on movement both hip joints
  • 38. Pelvic wrappingRoll on her left side
  • 39. External fixator
  • 40. Case II: 37 year-old male• Short gun wound abdomen• Unstable vital signs on arrival
  • 41. Case III: 48 year-old male• gunshot wound ? At posterior right tight• Unstable vital signs on arrival• No abdominal sign on arrival
  • 42. ConclusionATLS initial assessment• Primary survey• Adjunct to primary surveySelect appropriate investigation(s) for the injury